lunedì 6 marzo 2006

Acute adult epiglottitis

Findings

Lateral x-ray view of the neck soft tissues. There is thickening of the epiglottis with narrowing of the airway. CT: Diffuse edema of the epiglottis and aryepiglottic folds is noted (Figure 2 and Figure 3). Edematous changes are noted in the midline in the base the tongue, perhaps related to endotracheal tube placement or perhaps part of the inflammatory process involving the epiglottis (Figure 2). A tracheostomy tube is noted in place. Bilateral soft tissue emphysema is noted (Figure 2 and Figure 3).

Epiglottitis is a rapid onset of inflammation in the supraglottic region of the oropharynx with inflammation of the epiglottis, aryepiglottic folds, and arytenoids. Epiglottitis is an uncommon disease. Incidence in adults is about 1 case per 100,000 per year. Adult epiglottitis is most frequently a disease of men, occurring during the fifth decade of life. Occurrence has decreased since introduction of the Haemophilus influenzae B vaccine. Epiglottitis is generally more common in nations that do not immunize against H influenzae type B. Risk of death is high due to sudden airway obstruction and difficulty intubating patients with extensive edema. Adult mortality rate ranges between 6%-7%. Mortality rate in pediatric cases is less than 1%. Male-to-female ratio is approximately 3:1. In the pediatric population, epiglottitis is most common in ages 3-7, although any age may be affected.

Symptoms encountered include: sore throat, odynophagia/dysphagia, usually no prodromal upper respiratory infection, fever, drooling, cervical adenopathy, stridor, tripod position (sitting up on hands with the tongue out and the head forward), hypoxia, and respiratory distress.

The causative agents are type B Haemophilus influenza, Staphylococcus, Streptococcus, and viruses. Swelling and edema cause airway compromise that often necessitates tracheal intubation to protect the airway. Diagnosis of epiglottitis is based upon clinical exam and history, radiography, and direct visualization of the epiglottis. Treatment includes intubation, or immediate formal tracheostomy or cricothyrotomy may be performed in the operating room, if the case is less severe. Those without signs of airway compromise may be managed without immediate airway intervention by close monitoring in ICU.